Structure, Process, and Mortality Associated with Acute Coronary Syndrome Management in Guatemala's National Healthcare System: The ACS-GT Registry.

Background: Acute coronary syndromes (ACS) include ST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation myocardial infarction (NSTEMI), and unstable angina (UA). The leading cause of mortality in Guatemala is acute myocardial infarction (AMI) and there is no established national policy nor current standard of care. Objective: Describe the factors that influence ACS outcome, evaluating the national healthcare system's quality of care based on the Donabedian health model. Methods: The ACS-Gt study is an observational, multicentre, and prospective national registry. A total of 109 ACS adult patients admitted at six hospitals from Guatemala's National Healthcare System were included. These represent six out of the country's eight geographic regions. Data enrolment took place from February 2020 to January 2021. Data was assessed using chi-square test, Student's t-test, or Mann-Whitney U test, whichever applied. A p-value < 0.05 was considered statistically significant. Results: One hundred and nine patients met inclusion criteria (80.7% STEMI, 19.3% NSTEMI/UA). The population was predominantly male, (68%) hypertensive (49.5%), and diabetic (45.9%). Fifty-nine percent of STEMI patients received fibrinolysis (alteplase 65.4%) and none for primary Percutaneous Coronary Intervention (pPCI). Reperfusion success rate was 65%, and none were taken to PCI afterwards in the recommended time period (2-24 hours). Prognostic delays in STEMI were significantly prolonged in comparison with European guidelines goals. Optimal in-hospital medical therapy was 8.3%, and in-hospital mortality was 20.4%. Conclusions: There is poor access to ACS pharmacological treatment, low reperfusion rate, and no primary, urgent, or rescue PCI available. No patient fulfilled the recommended time period between successful fibrinolysis and PCI. Resources are limited and inefficiently used.

Atypical ischemic repolarization in right bundle branch block.

A 70-year-old male presented to emergency room 16 h after the onset of acute chest pain. Initial ECG showed sinus rhythm with a wide QRS and right bundle branch block (RBBB) with concordant and symmetric T waves in V1-V2. A plausible explanation for the atypical positive T waves in leads V1-V2 in conjunction with RBBB could be non-reperfused lateral MI (LMI) as a "mirror-image" of inverted T waves in the posterior leads V7-V9. Coronary angiography showed total thrombotic occlusion TIMI thrombus grade 5 of the circumflex artery. One ECG expression of circumflex artery occlusion is isolated LMI.

Case report: Posterior myocardial infarction in presence of right bundle branch block: an old concept with new findings.

BACKGROUND: The diagnosis of acute ischaemic coronary syndromes in presence of an intra-ventricular conduction disturbance represents a clinical challenge. In the cardiac segmentation model the posterior wall is replaced by the basal inferior segment. However, in the clinical scenario of acute coronary syndrome the concept of posterior myocardial infarction (PMI) endures. The association of a PMI and right bundle branch block (RBBB) is a rare condition characterised by broad R waves and ventricular repolarization disorders in right precordial leads in both entities, which could lead to misinterpretation and delay in reperfusion therapy. CASE SUMMARY: We describe a case report of a 74-year-old man with acute chest pain and an electrocardiogram with broad R waves, a 4 mm ST-segment downsloping (excessively discordant) in right precordial leads, RBBB, and ST-segment elevation in posterior leads. There was resolution of ST-segment downsloping in right precordial leads after percutaneous coronary intervention and stenting of the circumflex artery, with disturbance of the repolarization process only attributable to RBBB. DISCUSSION: Patients with acute chest pain with RBBB and a ST segment with an excessive downsloping (out of proportion of what is expected in isolated RBBB) suggest PMI with occlusion of the circumflex coronary artery.

Erradicación de diabetes en Guatemala: un sueño posible / A dream to achieve: diabetes erradication in Guatemala

La diabetes mellitus es un problema de salud con alcances económicos y sociales. La prevalencia mundial está aumentando: se estima que para 1985 había 30 millones de personas con diabetes, 177 millones en el año 2000 y se estima que para el año 2030 habrá 438 millones de diabéticos. En Guatemala el 8% de la población tiene diabetes y se desconoce el porcentaje no diagnosticado y en pre-diabetes; además el país tiene índices de obesidad, sobrepeso y sedentarismo altos, situación que predispone a la aparición de la enfermedad. En el mundo cada 6 segundos muere alguien a causa de complicaciones relacionadas con diabetes y en Guatemala ocupa la tercera causa de mortalidad general. Existen varios tipos de diabetes, sin embargo, el ensayo se enfoca en la diabetes tipo 2 debido a que representa el 90% de los casos pero sobre todo por que es prevenible. Para el autor existen tres momentos importantes de los pacientes diabéticos: (1) paciente sano y con riesgo qué enfermará de diabetes, (2) paciente diabético que tendrá complicaciones y (3) pacientes con complicaciones que morirán. En los tres momentos se puede intervenir directamente, sin embargo, existen deficiencias como la ausencia de programas de prevención y la ineficiencia del sistema asistencial público. El autor propone posibles soluciones en base a evidencia científica para detener el aumento de casos de diabetes mellitus, disminuir las complicaciones micro y macro vasculares en los pacientes y principalmente, generar una cultura preventiva en Guatemala.

Diabetes is a health problem with social and economic consequences. The worldwide prevalence of diabetes is raising; by 1985 there were 30 million of people with diabetes, 177 million by the year 2000 and it is estimated that in 2030 there will be around 438 million people with diabetes. The prevalence of diabetes in Guatemala it’s around 8% of the population, however it is unknown the prevalence of the underdiagnosed and pre-diabetes. Guatemala has high obesity, overweight and sedentary index which increase the risk of diabetes. Worldwide every 6 seconds somebody dies as a consequence of diabetes and in Guatemala represents the third cause in general mortality. The analysis is made about type 2 diabetes which represents 90% of all diabetes and in general is preventable. The author proposes 3 moments in the diabetes natural history: (1) healthy patients that will become diabetics, (2) diabetics who will have a complication related to the disease and (3) complicated patients who will decease. During these three moments there are interventions to be done, however there are non-preventable programs and the inefficiency of the public assistant system. The author proposes possible solutions in base of scientific evidence to stop the raising of diabetes, lowering micro and macro vascular complications and overall to generate a preventive culture in Guatemala.